The Mollring Cutter™ Remote Endarterectomy: Preliminary Experience with a New Endovascular Technique for Treatment of Occlusive Superficial Femoral Artery Disease

An Update on Endovascular Therapy of the Lower Extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Does Conversion of Intended Remote Iliac Artery Endarterectomy Alter the Early and Long-Term Outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures.

From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39–83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures.

Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 ± 15% to a primary assisted patency of 88 ± 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 ± 7.4%. The primary and secondary patency rates in group 2 were 86 ± 19% and 100%, respectively.

RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Single-Center Experience With Remote Endarterectomy for the Treatment of Long-Segment Superficial Femoral Artery Occlusion: Long-Term Results

OBJECTIVES

Remote endarterectomy (RE) is a relatively minimally invasive procedure as an alternative to femoropopliteal above-knee bypass for the treatment of long-segment superficial femoral artery (SFA) occlusion. The objective of this study was to report our experience and to evaluate the long-term outcome.

DESIGN

Single-center nonrandomized retrospective study with prospective collection of patients' data.

METHODS

Twelve patients (11 men; mean age 72 years, range 55-81 years) with long (>10 cm) SFA occlusion underwent RE followed by stent (aSpire) placement at the distal end of the endarterectomy. All patients had at least 2 tibial vessels outflow. Indications were severe claudication in 9 (75%), rest pain in 1(8%), and gangrene in 2 (17%) cases. Technical, hemodynamic success rates and clinical improvement were recorded. Assessment of patency and limb loss was made at a mean follow-up of 50 months (range 12-66 months).

RESULTS

Technical success rate was 100%. Immediate hemodynamic and clinical improvement were 92% and 75%, respectively. The mean increase in the Ankle-Brachial pressure index was 0.24. The primary, primary-assisted, and secondary patency rates were 50%, 83%, and 100%, respectively. The perioperative mortality rate was 8% (one death due to myocardial infarction). There was no early (30-day) reocclusion. During the follow-up, 5 (41.6%) cases underwent 7 reinterventions, all by endovascular means. The amputation rate was 16% (2 of 12).

CONCLUSIONS

The RE for long SFA occlusion is a feasible procedure with acceptable short- and long-term outcomes in the presence of distal arterial outflow. Good long-term patency and limb salvage can be achieved with close surveillance and with the compensation of endovascular reintervention procedures.

An update on endovascular therapy of the lower extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Simple technique to decrease total clamping time during combined iliac and femoral endovascular procedures

PURPOSE

To describe an alternative method of gaining vascular access while preserving blood flow to the profunda femoral artery during combined iliac and superficial femoral artery (SFA) recanalization.

TECHNIQUE

A sheath is introduced through the occluded SFA to reduce the total ischemic time when both the external iliac artery and SFA are obstructed. After iliac stenting and remote endarterectomy of the SFA with stent-graft deployment, blood flow to the profunda is interrupted only briefly when the proximal anastomosis of the femoral endobypass is completed.

CONCLUSIONS

Sheath insertion into the proximal portion of an occluded SFA can be an effective option in reducing ischemic time when dealing with combined iliac and femoral endovascular procedures.

Remote superficial femoral artery endarterectomy and distal vein bypass for limb salvage: initial experience

PURPOSE

To examine the results of remote superficial femoral artery endarterectomy (RSFAE) performed through a small groin incision in conjunction with distal saphenous vein (SV) bypass for limb salvage.

METHODS

A retrospective study was conducted of 21 patients (14 men; mean age 68.5 years, range 47-78) who underwent RSFAE and distal SV bypass between May 1998 and September 2001 for limb salvage. Thirteen had gangrene and 8 had rest pain. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy; the distal atheromatous plaque was "tacked up" with a stent. Distal SV bypass from the proximal popliteal artery was performed in situ in 7, from a transposed harvested vein in 8, or from a reversed graft in 6. All patients underwent follow-up examination with serial color-flow ultrasound scans.

RESULTS

The mean length of the endarterectomized SFA was 26.5 cm (range 12-40). There were no deaths, only 2 wound complications, and the mean hospital length of stay was 3.1+/-0.6 days. The primary cumulative patency rate by life-table analysis was 71.4% with follow-up extending to an average of 12.4 months (range 1-18). There were 2 amputations for gangrene and 6 percutaneous procedures in 4 (19.1%) patients to maintain bypass patency, producing an assisted primary patency rate of 81.5%. The locations of the restenoses were evenly distributed along the endarterectomized SFA and SV graft.

CONCLUSIONS

When adequate SV is not available, RSFAE with residual SV bypass is a safe and moderately durable procedure that may prove to be a useful adjunct for limb salvage, especially in the presence of foot infection, where an autogenous tissue bypass is preferred.

Use of a balloon-expandable, radially reinforced ePTFE endograft after remote SFA endarterectomy: a single-center experience

PURPOSE

To report our experience with endovascular femoropopliteal bypass grafting using a distensible, radially reinforced polytetrafluoroethylene endograft combined with remote endarterectomy.

METHODS

Forty-one patients (33 men; mean age 70 years, range 45-79) with symptomatic femoropopliteal occlusive disease underwent remote endarterectomy of the superficial femoral artery (SFA) followed by implantation of a balloon-expandable Enduring endovascular graft. All patients entered an extensive surveillance program, including angiography and duplex scanning at regular intervals.

RESULTS

Endarterectomy and endograft implantation were ultimately successful in all patients; 5 (12%) technical difficulties occurred intraoperatively and were treated with additional endovascular techniques. Control angiography at 1 week postoperatively demonstrated a patent endograft in 39 (95%) patients. Mean ankle-brachial index increased significantly from 0.57 to 0.91 (p < 0.001). Including the 2 early failures, 18 occlusions were documented over a median 15-month follow-up (range 3-24), due mainly to significant stenosis at the proximal and distal anastomoses. In 8 of 10 successfully reopened and revised endografts, reocclusion occurred after a median interval of only 1.8 months. Life-table analysis revealed cumulative primary and secondary patency rates of 42% and 56%, respectively, at 18 months. In the last 12 cases, the proximal end of the graft was sutured end-to-end to the transected SFA, which improved the short-term secondary patency rate to 83%.

CONCLUSIONS

Insertion of the Enduring endovascular graft following remote endarterectomy effectively results in a less invasive treatment for femoropopliteal occlusive disease. Additional technical refinements of the procedure may be required to avoid early procedure- and graft-related failures.

Open subintimal angioplasty of the superficial femoral and distal arteries

PURPOSE

To describe an open approach to subintimal angioplasty.

TECHNIQUE

Through a subinguinal incision and arteriotomy over the superficial femoral artery origin, the opening of a subintimal channel is created surgically. The subintimal plane is advanced distally with a guidewire, and this neolumen is expanded with sequential balloon dilations. The atherosclerotic core is dissected proximally in the common femoral artery and tacked down to ensure inflow. A patch graft closes the arteriotomy.

CONCLUSIONS

Open subintimal angioplasty is a simple, minimally invasive alternative treatment for complete SFA occlusion. Long-term follow-up in a large group of patients will be necessary to determine the durability of the false arterial lumen.

Superficial femoral endarterectomy with intra-arterial PTFE grafting

PURPOSE

To report early experience with a new endovascular approach to treating occluded Wallstents in the superficial femoral artery (SFA).

METHODS AND RESULTS

A symptomatic female patient with a 20-cm SFA occlusion involving a 10-cm Wallstent placed 2 years previously was offered an endovascular intervention. However, when percutaneous recanalization techniques failed, a semiclosed endarterectomy was undertaken using a conventional ring stripper. Although the atherosclerotic core and stent were removed smoothly, a small perforation was seen in the distal SFA. To avoid surgical repair, the endarterectomized segment was lined endoluminally using a 3-mm diameter, thin-walled polytetrafluoroethylene graft. A 15-mm Palmaz stent was used for distal fixation, with a plasty procedure performed at the proximal arteriotomy. There were no postoperative complications, and the patient, who was discharged on the second day, remains asymptomatic with normal flow through the graft at 3 months.

CONCLUSION

Newer endovascular techniques may be applied in concert with conventional semiclosed endarterectomy to successfully treat lengthy SFA occlusions, particularly those involving stents.

The cost-effectiveness of treatment of short occlusive lesions in the femoropopliteal artery: balloon angioplasty versus endarterectomy

OBJECTIVE

To compare the short- and long-term outcome and the costs involved in balloon angioplasty (BA) and thromboendarterectomy (EA) of short femoropopliteal occlusions.

DESIGN

Retrospective study.

PATIENTS AND METHODS

Forty-one lower limbs underwent EA from 1980 until 1988 and BA was performed in 62 limbs between 1988 and 1993. The two groups of patients were well matched for age, gender, cardiovascular risk-factors and the length of the femoropopliteal occlusions. In addition to clinical follow-up colour-Duplex scanning and intraarterial DSA were performed. Complete occlusions or significant restenoses were considered failure of the reconstruction. Actual costs were calculated by the hospital economic administration.

RESULTS

The 3-year primary patency in EA patients was 87% and in the BA group 44% (p = 0.0002). Redo procedures were required in seven (17%) patients with EA and in 24 (39%) with BA. Patency after redo procedures, i.e. tertiary patency, was 94% and 74% after 3 years in the EA and BA group respectively (p = 0.14). The mean cost of the primary treatment was higher in EA than in BA patients (p < 0.0001). Mean total treatment costs including the expenses involved with redo procedures were also higher in the group with EA than with BA (p < 0.001). However, the cost-effectiveness expressed as the total costs per month tertiary patency, was not significantly different for the two treatment groups; in patients with EA the ratio of total treatment costs and tertiary patency was NFl 309, and in patients with BA NFl 287.

CONCLUSION

Contrary to the general view the expenses associated with surgical treatment are comparable with those of an endovascular procedure, if the costs are expressed as a cost-to-patency ratio.